Southeastern Surgical Congress

Application for Fellowship

Categories of Fellowship

TYPES OF FELLOWS — Fellowships are unlimited in number and are composed of Regular Fellows, Associate Fellows, Affiliate Fellows, Resident Fellows, and Honorary Fellows.

REGULAR FELLOW — A surgeon who is a diplomat of an approved surgical Board* who resides in the territory of the Congress.

AFFILIATE FELLOW — A surgeon who has completed an approved residency but has not passed the respective Board exams. Dues shall be the same as for Regular Fellows.

ASSOCIATE FELLOW — A surgeon who is a diplomat of an approved surgical board* who resides outside the territory of the Congress.

RESIDENT FELLOW — A resident who is in training in an approved residency program.** Dues are minimal and include a subscription to The American Surgeon.

* Approved by the American Board of Medical Specialties

** Approved by the Accreditation Council for Graduate Medical Education

All areas must be completed before processing can begin. Applicants for Fellowship must include three references.

Type of Fellowship * Name * Birth Date *

Primary Address

Where do you want all correspondence sent? *

Home Office
Street Address * Suite * City * State * Zip Code * Primary Phone Primary Fax Primary Email

Secondary Address

Home Office
Street Address * Suite * City * State * Zip Code * Secondary Phone Secondary Fax Primary Email

Education and Training

Undergraduate Institution Dates Attended Major

Post-graduate Institution Dates Attended Major

Medical School Dates Attended Major

Internship Institution Dates Attended Major

Residency Institution Dates Attended Major

Fellowship Institution Dates Attended Major

Board Certification

Specialty Dates

Membership in Medical and Surgical Organizations

(please list):

Hospital and Teaching Affiliations:

Bibliography

(add additional pages if necessary or include CV):

References

Name * Address * City * State * Zip Code * Phone Email Name * Address * City * State * Zip Code * Phone Email Name * Address * City * State * Zip Code * Phone Email

Click “Submit” below!